Humor intervention in the nurse-patient interaction

A scoping review was performed using the Arksey and O’Mally methodology. A search for articles published between 2008 and 2018 was performed using the platforms EBSCO Host, Virtual Health Library and Google Scholar.

Results:

From the initial 465 articles found, 17 were included for final revision. Data allowed to retrieve information on humor definition; its applicability as a nursing intervention; humor as a tool to improve nurse-patient communication and relationship; influence factors; type of humor interventions; humor benefits in health care context and; limitations and precautions of humor intervention.

Conclusion:

The use of humor promotes both communication and human interaction; it promotes well-being; helps deal/cope with difficult and unpleasant situations, reduces tension, discomfort and stress; and strengthens the immune system. This intervention should be used with caution.

Descriptors:
Communication; Nurse-Patient Relations; Wit and Humor as Subject; Nursing; Patient Outcome Assessment

Author(s), year, location	Population	Aims	Methods	Results
Bennett et al., 2014, Australia⁽²³23 Bennett PN, Parsons T, Ben-Moshe R, Weinberg M, Neal M, Gilbert K, et al. Laughter and humor therapy in dialysis. Semin Dial[Internet]. 2014 [cited 2019 Mar 03];27(5):488-93. Available from: https://doi.org/10.1111/sdi.12194 https://doi.org/10.1111/sdi.12194... ⁾.	11 articles about humor on different populations	To identify the evidence related to laughter and humor therapy in people undergoing hemodialysis.	Narrative Review (NR).	Therapeutic interventions range from humorous videos, stories, laugh clowns through shrill simulated laughter and Laughter Yoga. The effect of laughter and humor on depression, anxiety, pain, immunity, fatigue, sleep quality, respiratory function and glucose levels may have applications for the context of dialysis and requires more research.
Branney et al., 2014, United Kingdom ⁽¹⁶16 Branney P, Witty K, Braybrook D, Bullen K, White A, Eardley I. Masculinities, humour and care for penile cancer: a qualitative study. J Adv Nurs[Internet]. 2014 [cited 2019 Mar 03];70(9):2051-60. Available from: https://doi.org/10.1111/jan.12363 https://doi.org/10.1111/jan.12363... ⁾.	10 men with penile cancer	To explore how men with penile cancer build humor in relation to their diagnosis and treatment.	Qualitative. Focus group. Nvivo analysis.	Humor helped participants to minimize their condition, which meant they could laugh about the treatment consequences and build a relationship with health professionals. The results suggest a combination of functionalism, relief, and humor incongruity theories. When appropriated, nurses should continue to use humor to build a relationship with people in illness process. Jokes about sexual and urinary function should be avoided.
Buxman, 2008, United States of America ⁽¹⁹19 Buxman K. Humor in the OR: a stitch in time? AORN J[Internet]. 2008 [cited 2019 Mar 03];88(1):67-77. Available from: https://doi.org/10.1016/j.aorn.2008.01.004 https://doi.org/10.1016/j.aorn.2008.01.0... ⁾.	Articles about the use of humor in the perioperative period	To explore the use of humor in the perioperative context.	NR.	Humor has multiple purposes and offers numerous benefits for both health professionals and patients. In the perioperative context, humor can be used to establish relationships, relieve anxiety, release anger in a socially acceptable way, avoid or deny painful feelings, and facilitate learning. Nurses in this context can use a variety of techniques and resources to increase the use of humor.
Haydon et al., 2015, Australia⁽¹⁵15 Haydon G, van der Reit P, Browne G. A narrative inquiry: humor and gender differences in the therapeutic relationship between nurses and their patients. Contemp Nurse[Internet]. 2015[cited 2019 Mar 03];50(2-3):214-26. Available from: https://doi.org/10.1080/10376178.2015.1021436 https://doi.org/10.1080/10376178.2015.10... ⁾.	4 nurses	To explore the experiences of four nurses on the use of humor in relation to gender differences and how it influences the therapeutic relationship.	Qualitative Narrative inquiry.	The study revealed gender differences on how humor is used by patients. For women, humor is often instantaneous and linked to the situation. It is used to facilitate communication for others. On the other hand men generate humor through stories and anecdotes. This is designed to establish a sense of balanced power between the patient and nurse.
Haydon & Riet, 2014, Australia⁽⁹9 Haydon G, Riet PV. A narrative inquiry: how do nurses respond to patients' use of humor?. Contemp Nurse[Internet]. 2014[cited 2019 Mar 03];46(2):197-205. Available from: https://doi.org/10.5172/conu.2014.46.2.197 https://doi.org/10.5172/conu.2014.46.2.1... ⁾.	4 nurses	To report the perceptions of four nurses on humor initiated by patients; how nurses react to patient's humor in the clinical setting.	Qualitative. Narrative inquiry.	Humor is a very personal concept. What a person thinks is funny does not necessarily make the other smile, as it may even be painful. Humor is an important communication tool for patients, as it humanizes nursing care, creates a bond and opens communication channels. Humor has the potential to change a patient's experience during hospitalization
Jone & Tanay, 2016, United Kingdom⁽²⁰20 Jones P, Tanay MA. Perceptions of nurses about potential barriers to the use of humor in practice: a literature review of qualitative research. Contemp Nurse [Internet]. 2016 [cited 2019 Mar 03];52(1):106-18. Available from: https://doi.org/10.1080/10376178.2016.1198235 https://doi.org/10.1080/10376178.2016.11... ⁾.	7 articles	To identify studies about nurses' perceptions of potential barriers to the use of humor in practice.	Systematic Literature Review (SLR) Qualitative studies.	The review and thematic analysis identified five key themes: (1) inadequate situations, (2) being a new or junior nurse, (3) impact on nurse professionalism, (4) differences in personality, and (5) environmental factors. Conclusion: the results identified nurses' perceptions about possible barriers that prevent the use of humor in practice. The extent to which nurses use humor is related to personality factors, but it is also affected by external and social factors. The reluctance in its use in practice is influenced by views that humor is not professional; with senior nurses found to have a relevant role in influencing its use.
Liptak et al., 2014, United States of America ⁽¹⁷17 Liptak A, Tate J, Flatt J, Oakley MA, Lingler J. Humor and laughter in persons with cognitive impairment and their caregivers. J Holist Nurs[Internet]. 2014 [cited 2019 Mar 03];32(1):25-34. . Available from: https://doi.org/10.1177/0898010113500075 https://doi.org/10.1177/0898010113500075... ⁾.	20 people with cognitive impairment	To describe humor and laugh in people with cognitive impairment (PWCI) through a caregiver focus group.	Qualitative.	Humor and laughter were present in all four focus groups. Emerging themes of humor included foolish, sarcasm and comments on the difficulties of dementia. Laughter was identified in segments with and without humor. Humor and laughter played a role in creating a safe social environment. Some people with dementia had difficulty recognizing social signs of mood
McCreaddie Wiggins, 2008, United Kingdom ⁽²⁴24 McCreaddie M, Wiggins S. The purpose and function of humor in health, health care and nursing: a narrative review. J Adv Nurs[Internet]. 2008 [cited 2019 Mar 03];61(6):584-95. Available from: https://doi.org/10.1111/j.1365-2648.2007.04548.x https://doi.org/10.1111/j.1365-2648.2007... ⁾.	88 articles on the topic humor	To identify, analyze and synthesize the humor literature related to health, health care and nursing.	NR	Humor in the physician-patient interaction demonstrates that its use by people in the process of illness is challenging and revealing, especially with regard to self-deprecating humor. Nurses should adopt a cautious and evidenced-based approach for the use of humor in their work.
Pinna et al. 2018, Spain⁽²⁵25 Pinna MÁ, Mahtani-Chugani V, Sánchez Correas MÁ, Sanz Rubiales A. The use of humor in palliative care: a systematic literature review. Am J Hosp Palliat Med[Internet]. 2018 [cited 2019 Mar 03];1:1049909118764414. Available from: https://doi.org/10.1177/1049909118764414 https://doi.org/10.1177/1049909118764414... ⁾.	34 articles on the topic humor	To understand the significance, suitability and relevance of humor in palliative care and analyze its applicability.	NR. PROSPERO.	Thirty-four studies were included. Five main topics were identified: (1) humor definition, (2) humor use and applicability in palliative care, (3) how to use humor, (4) when does not to use humor, and (5) humor before and after diagnosis of terminal disease. In the palliative care context the function of humor can be classified into three main topics: building relationships, as it improves relations between patient and family, patient and health professionals and between health professionals and families, leading to bonding, developing trust and providing more relaxed relationships, reducing levels of fear and distance between people, strengthening and consolidating therapeutic relationships: it allows the management of conflicts through communication and active listening of health professionals, being a channel to discuss complex issues, such as death, giving information and transmitting bad news; finally, it allows the expression of feelings, recognizing people as human beings and bringing humanity to the health professional. It facilitates the relationship with others, as it helps to foster the understanding of the person, of others and of oneself. The physical benefits from the use of humor are relaxation, pain reduction and it helps to deal with other symptoms. Conclusions: humor plays an unquestionable role in palliative care, but its use requires adequate training and use.
Santos et al., 2016, Portugal⁽²²22 Santos CF, Sousa LM, Carvalho ML, Severino SS, José HM. A intervenção Humor em enfermagem num serviço de ortopedia: estratégias e benefícios. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(16):36-44. Available from: http://hdl.handle.net/10400.17/2623 http://hdl.handle.net/10400.17/2623... ⁾.	11 nurses	To identify the strategies and benefits of humor intervention in orthopedics.	Content analysis.	This study aims to contribute to the understanding of humor intervention, namely: aspects to be taken into account in the evaluation, planning and implementation of this intervention; and the main benefits in the health and well-being of hospitalized people. For this intervention can be used countless resources such as jokes, antics, jokes, anecdotes, puns, surprises, funny situations, personal experiences, comic comments, spontaneous expressions comic, music and movies. The main indirect benefits mentioned are: improving relationships, trust, participation and involvement in care, proximity, motivation, breaking barriers, optimism, good disposition and adherence to treatment. The main direct benefits mentioned were: recovery improvement, stress reduction, relaxation and relief of tension, distraction, pain reduction, exteriorization of feelings, adaptation mechanisms, quality of life improvement, learning facilitator, reduction of anxiety.
Sousa & José, 2016, Portugal⁽³3 Sousa LM, José HM. Benefícios do humor na saúde: revisão sistemática da literatura. Enformação [Internet]. 2016[cited 2019 Mar 03];7:22-32. Available from: http://hdl.handle.net/10884/992 http://hdl.handle.net/10884/992... ⁾.	26 studies on humor in health care	To identify the role of humor in people's lives and health.	SLR.	Humor has benefits at both the organizational and health care level. When using humor teams are more productive, cohesive, show less stress and are more motivated and satisfied. In health and people's life humor promotes well-being; helps to deal with difficult and unpleasant situations, reduces tension, stress and discomfort; increases tolerance to pain, and strengthen the immune system.
Sousa & José, 2013, Portugal⁽⁶6 Sousa LM, José HM. Revisão integrativa sobre a intervenção do humor na enfermagem. Rev Cienc Med[Internet]. 2013[cited 2019 Mar 03];9(20):307-8. Available from: http://hdl.handle.net/10884/1018 http://hdl.handle.net/10884/1018... ⁾.	15 articles on the humor intervention in nursing	To characterize the scientific evidence on humor intervention in nursing care.	Integrative Literature Review (ILR).	The humor intervention is complex, since humor is paradoxical, situational, multifaceted and its use has to be weighed in some situations, namely in persons with cognitive impairment, mental illness and in situations of severe illness. However, when a nurse makes an appropriate assessment, it seems to have numerous benefits to health and well-being. The use of humor facilitates communication and relationship with the cared person and helps professionals deal with and overcome difficulties intrinsic to their profession.
Sousa et al., 2016, Portugal⁽²¹21 Sousa LM, Marques-Vieira C, Severino S, Pozo Rosado JL, José HM. Fatores explicativos da apreciação de filmes cómicos em pessoas com doença renal crónica. Rev Inv Enferm[Internet]. 2016[cited 2019 Mar 03];S2(15):49-55. Available from: http://hdl.handle.net/10400.17/2622 http://hdl.handle.net/10400.17/2622... ⁾.	171 people with chronic kidney disease undergoing hemodialysis	To Identify the factors that influence the enjoyment of humorous films in people with chronic kidney disease; and identify the humorous movies most enjoyed by them during hemodialysis session.	Mixed. Content analysis.	People with chronic kidney disease who enjoy humorous movies are considered to be cheerful and fun. They also report to have sense of humor and a fun family. In addition, they mention liking to play, to laugh, to be made to laugh, to be with people with a sense of humor, to listen to anecdotes, to read comic books and to listen to funny stories. This study identified the sociodemographic and clinical factors related to the sense of humor and that influence the appreciation of humor films. It also identified the main types of humorous / humorous movies / videos enjoyed by people with chronic kidney disease. This study brings important contributions to the nursing intervention humor which is part of the Classification of Nursing Interventions.
Sousa et al., 2015, Portugal⁽²2 Sousa LM, Carvalho ML, Santos CF. Tipos de humor utilizados na prestação de cuidados pelos enfermeiros num serviço de Ortopedia. Enformação [Internet]. 2015[cited 2019 Mar 03];6:13-9. Available from: http://hdl.handle.net/10884/1015 http://hdl.handle.net/10884/1015... ⁾.	11 nurses	To identify the meaning of humor for nurses; and identify the types of humor used in nursing practice.	Content analysis.	Results showed that nurses identified the following manifestations of humor: laughter, smile, joy, and a state of mind and well-being. The types of humor found are positive/healthy and negative/unhealthy
Sousa et al., 2018, Portugal⁽⁷7 Sousa LM, Teixeira PM, Marques-Vieira CM, Severino SS, Faísca H, José HM. Emploi de l'humour dans la relation infirmier/personne malade: une revue de la littérature et synthèse. Rev Francoph Int Rech Infirm[Internet]. 2018[cited 2019 Mar 03];4(1):30-8. Available from: https://doi.org/10.1016/j.refiri.2017.07.011 https://doi.org/10.1016/j.refiri.2017.07... ⁾.	7 articles with qualitative methodology	To identify the factors that influence the use of humor in nursing care from patient perspective	SLR.	Factors influencing the use of humor and its benefits in nursing care were identified. For nurses, humor is humanizing, generating emotions, reducing tensions, improving communication and hospital experience. It is influenced by gender, context, culture, self-esteem and nurses' confidence. From the perspective of people with illness, humor presents benefits as it generates greater participation in the therapeutic interaction
Tanay et al., 2013, United Kingdom ⁽¹⁸18 Tanay MA, Roberts J, Ream E. Humor in adult cancer care: a concept analysis. J Adv Nurs[Internet]. 2013 [cited 2019 Mar 03];69(9):2131-40. Available from: https://doi.org/10.1111/jan.12059 https://doi.org/10.1111/jan.12059... ⁾.	12 articles	To Analyze the concept of humor in the treatment of cancer in adults.	Content analysis. According to the Walker & Avant model.	Humor is a subjective emotional response, resulting from the recognition and expression of incongruities of a comical, absurd and impulsive situation, observation, character or action, which enhances feelings of closeness or union when shared in the context of trust between patient and nurse. It can be used as an adjustment mechanism in a stressful situation, such as the cancer treatment in adults.
Tremayne, 2014, United Kingdom ⁽¹⁰10 Tremayne P. Using humor to enhance the nurse-patient relationship. Nurs Stand[Internet]. 2014[cited 2019 Mar 03];28(30):37-40. Available from: https://doi.org/10.7748/ns2014.03.28.30.37.e8412 https://doi.org/10.7748/ns2014.03.28.30.... ⁾.	Articles about humor	To discuss how humor can promote physiological and psychological well-being, while reducing stress and anxiety	SLR.	The proper use of humor is a valuable resource for nursing practice. When used in daily interactions with patients, humor can help develop the therapeutic relationship and build resilience. Humor can promote physiological and psychological well-being while reducing stress and anxiety.

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[1] Corresponding Author: Luis Manuel Mota Sousa E-mail: luismmsousa@gmail.com